198602545-8-3-2023-28-AS-EZAA-CUCP3N-20230803105750

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602545
Report Date: 08/03/2023
Date Signed: 08/03/2023 10:58:10 AM

Document Has Been Signed on 08/03/2023 10:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	HOLY HILL INC-MAPLEDALE HOME		FACILITY NUMBER:	198602545
ADMINISTRATOR:	SANTOS, MARIA TERESA F		FACILITY TYPE:	735
ADDRESS:	11559 MAPLEDALE STREET		TELEPHONE:	(562) 506-5010
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 3		CENSUS: 3	DATE:	08/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Noel De Los Reyes - DSP		TIME COMPLETED:	11:15 AM

NARRATIVE

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Noel De Los Reyes who is a caregiver at the facility and was granted access into the facility. Administrator Ronald Dino arrived shortly thereafter. There are three (3) ambulatory developmentally disabled clients who reside in the home. The facility is vendored through Harbor Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA asked administrator to send a completed infection control plan to LPA within 7 days.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of three (3) non-ambulatory developmentally disabled clients between the ages of 18-59, and one (1) hospice waiver. It consists of three (3) individual client bedrooms, a living room, dining room, a kitchen, one (1) shared client bathrooms (R1) which had a hot water temperature measured at 105.9 Degrees F, and a second private restroom (R2) which measured at 107.4 Degrees F, a main hallway which contained the facility’s laundry machines, a front and back patio area, and an attached garage which serves as a storage area for the facility.

· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Fire alarm system is operational.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/03/2023 10:58 AM - It Cannot Be Edited

Created By: Erik Zaragoza On 08/03/2023 at 10:46 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOLY HILL INC-MAPLEDALE HOME	FACILITY NUMBER: 198602545
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above in 3 out of 3 clients because during the inspection LPA observed that the last disaster drill was conducted in July of 2019, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/24/2023
	Plan of Correction
1 2 3 4	Administrator is to ensure that Fire and Earthquake drills will be condcuted at least once every 6 months and will include all facility staff who provide or supervise client care and supervision. Administrator is to ensure that a new fire and earthquake drill is to be conducted with the clients and photographic proof sent to LPA by 8/24/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

David Sicairos

LICENSING EVALUATOR NAME:

Erik Zaragoza

LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOLY HILL INC-MAPLEDALE HOME	FACILITY NUMBER: 198602545
	VISIT DATE: 08/03/2023

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The facility has two (2) fully charged fire extinguishers that are kept in the kitchen of the facility as well as in the laundry area. Cleaning supplies and toxic substances are inaccessible to clients.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for three (3) non-ambulatory clients.

· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of seven (7) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator’s certificate is active and effective through 12/17/2023..

· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Three (3) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and P & I money were reviewed.

Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOLY HILL INC-MAPLEDALE HOME	FACILITY NUMBER: 198602545
	VISIT DATE: 08/03/2023

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· No restricted Health Care plan required for the clients in the facility.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· Three (3) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incident Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

· A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.

· An emergency drill was last documented in July of 2019.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit are documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC809 (FAS) - (06/04)

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